Tutorial Cases: Celiac

Question 1

What are classic manifestations of celiac disease? (7)

Answer 1

Chronic/recurrent diarrhea
Abdominal distention
Anorexia/failure to thrive/loss of weight
Abdominal pain
Vomiting
Constipation
Irritability

Question 2

What are non-GI manifestations of celiac disease?

Answer 2

Appear during older child to adultDerm: herpetiformis
Bone: dental enamel hypoplasia
osteopenia, short stature
Delayed puberty, Fe-deficient anemia, hepatitis, arthritis

Question 3

What are disorders associated with celiac disease?

Answer 3

T1DM, thyroiditis, sjogren’s, chronic active hepatitis, lactose intolerance, IgA deficiency

Question 4

Which HLA type is strongly associated with celiac disease?

Answer 4

90-95% of patients have HLA-DQ2

This is present in about 20-30% of controls

Question 5

What dietary factor is associated with celiac?

Answer 5

Modified gladden peptide– leads to activation of CD4+ T cells in lamina propria and subsequent IFN-gamma secretion

Question 6

What testing is used for celiac disease diagnosis?

Answer 6

Biopsy for presence of serum gladden or endomysial antibodies in small bowel of patient ingesting gluten

Remission while on gluten-free diet

Question 7

Describe the histological findings for celiac disease (5)

Answer 7

Increased intraepithelial lymphocytes
Villous atrophy
Crypt hyperplasia
Enterocyte damage
Mixed inflammatory infiltrate

Question 8

What are the important serological markers of celiac disease?

Answer 8

EMA (IgA): sensitive/specific

TTG (IgA): highly sensitive/specific

Question 9

What is treatment for celiac disease?

Answer 9

A gluten-free diet

Question 10

What changes in epidemiology of eosinophilic gastroenteropathies have been observed in past 20 years?

Answer 10

Food hypersensitivity reactions affect up to 8% children under 3 and 2.5% of general population

There has been a 3x increase in prevalence of allergies in past 20 years due to environment, food process, abx usage

Question 11

What are three diseases on spectrum of eosinophilic gastroenteropathies?

Answer 11

Allergic proctocolitis
Eosinophilic gastroenteritis
Eosinophilic esophagitis

Question 12

Eosinophilic esophagitis presents with symptoms similar to ______, but in what way is its treatment/resolution different?

Answer 12

EoE presents with symptoms similar to GERD, but it is unresponsive to acid blockade and instead responds to removal of food antigen

Question 13

What are clinical findings of eosinophilic esophagitis? (3)

Answer 13

Allergic history (asthma, rhinitis, eczema)
Slightly elevated IgE
Responsive to corticosteroids

Uncommon to have peripheral eosinophilia

Question 14

What are gross findings in Eosinophilic esophagitis?

Answer 14

White plaques, rings/trachealization, lateral furrows

Question 15

Describe epidemiology of allergic proctocolitis: Prevalence, age, sex

Answer 15

2-6% children in developed countries

Patients typically

Question 16

What are clinical symptoms of allergic prococolitis? (4)

Answer 16

Blood streaked stools
Diarrhea
Mild abdominal pain
Weight gain, well-appearing

Question 17

What are laboratory features of allergic proctocolitis? (4)

Answer 17

Fecal leukocytes
Mild peripheral eosinophilia
Rarely, hypoalbuminemia/anemia
Pin prick/RAST testing negative

Question 18

What are provocative antigens? (3)

Answer 18

Cow’s milk protein or soy milk

50-60% are exclusively breast fed

Question 19

Describe the treatment and symptom resolution in allergic prococolitis

Answer 19

After foods removed, clinical symptoms improve within 72hr while diarrhea/bleeding resolve in 1-3 weeks.

Reintroduce foods later on

Question 20

Describe epidemiology of eosinophilic gastroenteritis

Answer 20

Rare, affects all ages

Unknown etiology

Question 21

What is another major cause of eosinophilia in GI tract?

Answer 21

Infections by parasites

Question 22

Describe the epidemiology of IBD

Answer 22

10-15% have established diagnosis before 15yo

Incidence increasing among pediatric patients